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Major surgery induces profound physiological
Consideration should be given to appropriate
premedication. In the fast-track surgical setting,
and impaired pulmonary function. These com-
premedication is aimed at reducing the surgical
plications can lead to delayed mobilization,
stress response. In this respect, there is increas-
prolonged hospital stay, and significant post-
b-Blockers suppress the surgically induced
increase in circulating catecholamines and can
Professor Henrik Kehlet in Denmark in the
therefore reduce perioperative cardiovascular
early 1990s.1,2 The term refers to a multimodal
morbidity. They also have analgesic-sparing
package of techniques which aim to decrease
and anticatabolic properties, which may facili-
post-surgical organ dysfunction and compli-
cations, and hence to improve postoperative
recovery. The centres that have pioneered this
opioid-sparing effects when used as premedica-
approach have achieved impressive reductions
tion. There is also evidence that they reduce
in hospital stay and surgical morbidity. The
perioperative myocardial ischaemia, intraopera-
tive blood loss, and postoperative nausea and
enhanced recovery) programmes, as applied to
major abdominal surgery, are reviewed here.
Each aspect uses evidence gleaned from the
shorten the duration of ileus and improve pain
attempts to integrate these ideas into a seamless
programme of clinical care. For this to be asuccess, the multidisciplinary team involved
Traditionally, patients for elective surgery are
Well-organized prospective audit is an import-
fasted overnight to reduce aspiration risk,
which may lead to significant dehydration.There is evidence that avoidance of preopera-tive dehydration can reduce postoperative pain
and nausea. Clear fluids taken orally up to 2 hbefore surgery have been shown to have no
effect on gastric volume and pH, and therefore
Postoperative organ dysfunction and compli-
no effect on aspiration risk. Clear carbohydrate
cations are related to preoperative co-morbidity.
fluids given before operation may also have a
Preoperative assessment allows estimation of
role. They reduce the sensations of thirst and
risk and an opportunity to stabilize co-existing
hunger, and in smaller trials have been shown
disease and optimize organ function before
to reduce anxiety levels. There is a reduction in
perioperative insulin resistance, and a small
reduction in perioperative muscle catabolism.
opportunity for patient education. In fast-track
Whether this translates into an effect on length
programmes, patients are given information
of hospital stay requires further study.
about their anticipated postoperative course,
Bowel preparation is traditionally adminis-
analgesia, mobilization programme, and dis-
tered to all patients before colorectal surgery.
charge. Several studies have demonstrated that
However, a recent meta-analysis has demon-
such information can reduce anxiety, analgesic
strated that, at least for segmental resections,
requirements, and length of hospital stay.
bowel preparation may not be necessary and
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 9 Number 2 2009
& The Author [2009]. Published by Oxford University Press on behalf of The Board of Directors of the British Journal ofAnaesthesia. All rights reserved. For Permissions, please email: [email protected]
may increase the risk of septic complications and aggravate preo-
are ideal. In order to minimize the incidence of PONV, total
i.v. anaesthesia (TIVA) is often favoured. In major abdominalsurgery, serious consideration should be given to the use of
thoracic epidural analgesia. Although there is no definitiveevidence that epidural analgesia reduces mortality, it has a number
Surgery initiates a complex metabolic, neuroendocrine, and inflam-
of other significant benefits in this population. In comparison with
matory stress response, which results in stimulation of the sym-
i.v. opioid-based patient-controlled analgesia regimes, epidural
pathetic nervous system, profound catabolism, and retention of
local analgesia better preserves exercise capacity after laparotomy,
sodium and water. These changes are not beneficial to the patient
reduces time to ambulation, provides better static and dynamic
and indeed most postoperative organ dysfunction and morbidity
pain relief, and reduces postoperative pulmonary complications
can be attributed at least in part to the stress response.
after upper abdominal procedures. Thoracic epidural analgesia can
Intraoperative management is aimed at reducing the stress response
reduce ileus after colorectal surgery, although not consistently after
to surgery, and facilitating early feeding and mobilization after
upper gastrointestinal tract surgery.
There has recently been some debate of the need for routine
use of epidurals for major abdominal surgery.7 The MASTER
trial8 showed that there was no reduction in mortality after major
abdominal surgery in the epidural group (although there was a
The use of minimally invasive surgical techniques reduces the
reduction in the incidence of respiratory failure when compared
inflammatory component of the stress response but does not appear
with i.v. analgesia). However, the MASTER trial did not address
to have significant effects on the neuroendocrine and metabolic
the issue of length of hospital stay, and was ambiguous regarding
response. However, minimally invasive surgery is generally associ-
early feeding, early mobilization, and other features of a fast-track
ated with reduced pain and shorter hospital stay when compared
programme. If mortality outcomes are not different in fast-track
with open techniques. This difference is most marked where the
programmes, but median length of stay is reduced by 3 days, our
open procedure requires a long vertical incision. Pain and pulmon-
view is that, at a time when healthcare is threatening to consume
ary dysfunction are reduced where transverse or oblique incisions
an ever greater proportion of our national income, a safe technique
are used instead of vertical, presumably due to the reduced number
which reduces length of hospital stay is a priority. This of course
brings its own benefits, including a reduction in hospital-acquired
Minimally invasive surgical approaches may not always be the
best technique. When fast-track surgical principles are applied toperioperative care, the differences in median length of hospital staybetween minimally invasive and open surgical techniques become
less marked. Particularly, in procedures where a long vertical
Ideal perioperative fluid management has been the subject of much
incision is not necessary, such as colonic resection, the advantages
debate. ‘Liberal’ fluid administration can reduce nausea and vomit-
of a minimally invasive approach are not clear-cut. Kehlet5 has
ing, dizziness, drowsiness, thirst, and hospital stay, particularly in
repeatedly argued that laparoscopic approaches to abdominal
minor-to-moderate and ambulatory surgery. However, overhydra-
surgery need to be evaluated within a fast-track programme to
tion can lead to cardiac and pulmonary dysfunction. Excess fluid
accurately assess their impact on length of stay and postoperative
may also reduce tissue oxygenation leading to impairment of
wound healing. Healing of the surgical anastomosis is a particularconcern. The salt and water retention induced by the surgical stress
Avoidance of routine nasogastric tubes and drains
response can exacerbate these problems. Conversely, fluid restric-
Nasogastric tubes have long been part of the routine care of
tion can reduce effective circulating volume and lead to inadequate
patients after major abdominal surgery. However, there is increas-
ing evidence that, at least for mid-to-lower abdominal procedures,
Preoperative volume status varies greatly, and the magnitude of
their use is not routinely indicated. Indeed, they may actually
the surgical insult (and the resulting stress response) can lead to
hinder recovery by prolonging paralytic ileus and predisposing to
very different fluid requirements. Hence, individually tailored goal-
pulmonary aspiration.6 Similarly, surgical drains may slow recov-
directed fluid therapy would appear to be the optimal approach,
ery of bowel function and make pain control difficult.
the goal being maintenance of tissue perfusion and cellular oxy-genation. This strategy is based on the assumption that the optimalblood volume for a given individual is defined by that preload
which is required to produce a maximal cardiac output (or stroke
Anaesthetic technique should be geared towards rapid recovery
volume). Starling’s law of the heart shows that successive fluid
with minimal carry over of opioid effects into the recovery period.
challenges (i.e. increasing preload) will increase the stroke volume
For this reason, short-acting anaesthetic and analgesic agents
until a given point (the flat portion of the curve). Beyond this,
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 9 Number 2 2009
further increases in preload will cause a reduction in stroke
evidence that epidural analgesia with local anaesthetics is associated
volume. Therefore, the goal for fluid therapy for an individual
with faster resolution of postoperative ileus after major abdominal
would be that point where a fluid challenge no longer produces an
surgery. Consideration should be given to a combination of local or
increase in stroke volume. Stroke volume can be estimated using a
regional anaesthetic techniques (including continuous infusion of
number of non-invasive methods, including oesophageal Doppler
wounds with local anaesthetic), paracetamol, non-steroidal anti-
and forms of pulse pressure analysis. Typically, successive fluid
inflammatory drugs (NSAIDs), and other agents such as gabapentin,
challenges of 250 ml colloid are given until this no longer pro-
clonidine, and ketamine. By using such an approach, the need for
duces an increase in stroke volume of at least 10%. This is thought
opioids should be reduced; this should minimize their side-effects
to represent optimal circulating volume. Several recent studies
(e.g. sedation, nausea, ileus, and urinary retention) all of which
have demonstrated a reduction in morbidity measures, particularly
hamper the aims of early mobilization and enteral nutrition.
length of stay and duration of ileus by using such an individualized
If a thoracic epidural is chosen as the main analgesic technique,
approach.10 Ultimately, it would be ideal to use a more direct
the appropriate level should be chosen to match the surgical
measure of tissue perfusion to guide fluid therapy. Various tech-
incision. For example, for most colorectal surgery, the level of the
niques such as gastric tonometry and near-infrared spectroscopy
incision lies between T8 and T11 dermatomal levels. An epidural
have been studied, but have not yet been well validated.
sited at T8/9 will spread easily upwards if the drug is injected manu-ally through a syringe. However, once connected to a volumetric
Prevention of postoperative nausea and vomiting
pump, the local anaesthetic seeps slowly into the epidural space, andthe influence of gravity then becomes important in the postoperative
Nausea and vomiting is a common complication of anaesthesia
period. With the patient sat up, the block will tend to sink. An epi-
and surgery. It causes patient distress and discomfort, and delays
dural sited at a lower thoracic level will thus struggle to cover the
resumption of a normal diet. Multimodal strategies to reduce the
upper level of the incision, but the lumbar roots may be persistently
incidence of PONV include adequate hydration, balanced analgesia
blocked, causing lower limb weakness, and impeding mobility.12
to minimize perioperative opioid use, avoidance of volatile anaes-
The importance of acute pain medical and nursing team review
thetic agents (although the effect of TIVA wears off after a few
cannot be overemphasized. At least twice daily review is needed,
hours), avoidance of nitrous oxide, and the administration of differ-
as a patchy epidural, or one not covering the wound incision can
ent types of antiemetic drugs. In particular, glucocorticoids (e.g.
be improved substantially, or even re-sited. It is crucial to maintain
dexamethasone) reduce the risk of nausea and vomiting, have an
the confidence of the patient in their pain relief if early mobiliz-
effect on reducing tissue swelling, and a small analgesic effect.
ation is to follow. We establish the block with either bupivacaine0.5% or in the elderly bupivacaine 0.25%, and then continue the
epidural infusion with bupivacaine 0.15% and fentanyl 2 mg ml21.Once connected, we try at all costs not to disconnect the infusion
Prevention of intraoperative hypothermia is important in minimiz-
again, as this increases the risk of infection. Most epidural cath-
ing the stress response. Hypothermia is associated with increased
eters are removed at 48 h, and all by 72 h. The risk of infection
wound infection, blood loss, and coronary events. Hypothermia
increases substantially if epidural catheters are left .72 h. Pain
also increases patient discomfort. Catecholamines and cortisol are
not covered by the epidural (e.g. shoulder tip pain) is treated with
also increased, which can further contribute to the stress response.
paracetamol or a NSAID. If the epidural does not cover the
Forced-air warming devices, warmed i.v. fluids, and warmed
incision, despite boluses from the pump, and an increase in the
humidified gases should be used, and patient temperature should
rate of infusion, the epidural is either re-sited or a patient-
be monitored continuously during surgery.
controlled analgesia opioid infusion started.
After epidural removal, the patient takes regular NSAID and
paracetamol, with severe breakthrough pain treated with oral mor-phine or tramadol. Severe pain at 72 h should raise the possibility of
intra-abdominal complications, and the patient must be carefully
Good analgesia is essential for postoperative mobilization and
reviewed by the surgical team. Our practice is normally to remove
resumption of normal activities. A cornerstone of fast-track surgery
the urinary catheter on the same day as the epidural catheter.
programmes is the use of multimodal or balanced analgesia. Theprinciple of this is to gain additive analgesic effects from different
modalities of pain control while minimizing side-effects, particularlythose of opioids. A recent systematic review of postoperative
Oral intake has traditionally been limited in the postoperative
analgesia concluded that due to the low incidence of complications,
period and, when allowed, has involved a gradual progression from
there was insufficient evidence to confirm or deny the ability of
liquid to solid food. However, adequate nutrition is important to
specific postoperative analgesic techniques to affect major post-
enhance wound healing, reduce infection, and maintain muscle
operative mortality or morbidity.11 However, there was consistent
strength for mobilization and to counter fatigue. Reduced
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 9 Number 2 2009
Table 1 Key components of a fast-track programme
2 – 4 days for resection of the colon. Concerns have been raisedthat this may have been achieved at the expense of increased
readmission rates or an increased burden on community healthcare
providers. However, this does not appear to be the case.
Successful implementation of a fast-track surgical programme
requires multidisciplinary collaboration between anaesthetists,
approach involving the pre-assessment clinic and clinical nurse
specialists and also ward and theatre staff. All staff involved
Air/O2/TIVA or quick-onset volatile agents
need to understand and be motivated by the principles of the
fast-track approach (Table 1). A clear care pathway is vital in
journey and defining clear discharge criteria. Roles of the
surgeon include: appropriate case selection; type and size of
Multimodal analgesiaAcute pain team managing epidural
incision; minimizing the use of drains; ensuring drains or cath-
eters used are removed promptly; early feeding; and early mobil-
ization. Roles of the anaesthetist include: the use of ananaesthetic technique with rapid recovery (consideration ofTIVA); optimal fluid balance; prevention of PONV; and a
Table 2 Fast-track programme outcomes (adapted from Kehlet)2
balanced analgesic regime ideally including thoracic epidural
Decreased cardiopulmonary morbidityIncreased muscle strength and exercise capacityDecreased length of hospital stay and reduced hospital costsNo effect on readmission rate
Fast-track surgical programmes involve implementation of a
nutritional intake contributes to catabolism and muscle wasting.
package of multidisciplinary evidence-based interventions which
Caution has been exercised with oral feeding after abdominal
have the potential for significant reductions in postoperative com-
surgery, particularly in the presence of a surgical bowel anastamo-
plications and length of hospital stay (Table 2). Anaesthetists have
sis. However, early enteral nutrition reduces gut permeability when
a key role to play in many of these interventions. There are still
compared with either late enteral feeding or parenteral nutrition.
areas of uncertainty where best practice remains to be elucidated.
This reduction in gut permeability is thought also to reduce bac-
These include the role of minimally invasive surgical techniques
terial translocation and hence infection. Several studies have
and the place of epidural analgesia.
shown that early oral intake is safe even after bowel resection.13
Postoperative ileus is common after abdominal surgery. It
increases pain and discomfort, hinders mobilization, and delays
oral nutritional intake. Strategies to reduce the incidence of ileus
1. White PF, Kehlet H, Neal JM, Schricker T, Carr D. The role of the
include the use of minimally invasive surgical techniques to reduce
anesthesiologist in fast-track surgery: from multimodal analgesia to peri-
the stress response and minimizing bowel handling, and also avoid-
operative medical care. Anesth Analg 2007; 104: 1380 – 96
ance of the routine use of nasogastric tubes as discussed above.
2. Kehlet H. Fast-track colorectal surgery. Lancet 2008; 371: 791 – 3
3. Wu CT, Jao SW, Borel CO et al. The effect of epidural clonidine on peri-
operative cytokine response, postoperative pain and bowel function inpatients undergoing colorectal surgery. Anesth Analg 2004; 99: 502 – 9
Prolonged bed rest after surgery is undesirable as it increases
4. Guenaga KF, Matos D, Castro AA, Atallah AN, Wille-Jorgensen P.
muscle loss and weakness, predisposes to venous stasis and throm-
Mechanical bowel preparation for elective colorectal surgery. Cochrane
boembolism, and impairs pulmonary function. Ambulation can
enhance gut mobility and therefore reduce any ileus. Effective
5. Kehlet H, Kennedy RH. Laparoscopic colonic surgery—mission accom-
plished or work in progress? Colorectal Dis 2006; 8: 514 – 7
analgesia is vital to allow early mobilization.
6. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression
after abdominal surgery. Cochrane Database Syst Rev 2007; 3: CD004929
7. Low J, Johnston N, Morris C. Epidural analgesia: first do no harm.
8. Rigg JR, Jamrozik K, Myles PS et al., MASTER Anaesthesia Trial Study
Where fast-track surgical programmes have been pioneered, post-
Group. Epidural anaesthesia and analgesia and outcome of major
operative inpatient stays have been reduced significantly, down to
surgery: a randomised trial. Lancet 2002; 359: 1276– 82
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 9 Number 2 2009
9. Delgado-Rodriguez M, Bueno-Cavanillas A, Lopez-Gigosos R et al.
12. Armitage EN. Thoracic and lumbar epidural block. In: Wildsmith JAW,
Hospital stay length as an effect modifier of other risk factors for noso-
Armitage EN, McClure JH, eds. Principles and Practice of Regional
comial infections. Eur J Epidemiol 1990; 6: 34 – 9
Anaesthesia. London: Churchill Livingstone, 2003; 139 – 67
10. Bundgaard-Nielson M, Holte K, Secher NH, Kehlet H. Monitoring of
13. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24 h of
peri-operative fluid administration by individualised goal-directed
colorectal surgery versus later commencement of feeding for
therapy. Acta Anaesthesiol Scand 2007; 51: 331 – 40
postoperative complications. Cochrane Database Syst Rev 2006; 4:
11. Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative
complications: a systematic update of the evidence. Anesth Analg 2007;104: 689 – 702
Please see multiple choice questions 1 – 4
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 9 Number 2 2009

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